Fibromyalgia comorbidity in primary headaches

Shared comorbidity of depression, migraine, insomnia, and fibromyalgia in a population-based sample

BACKGROUND

Depression, migraine, insomnia, and fibromyalgia are reportedly comorbidities. Nevertheless, no study has evaluated the comorbidity of all four of these disorders. This study aimed to investigate the comorbidity of these four disorders.

METHODS

Cross-sectional analyses were performed using data of the Circannual Change in Headache and Sleep study, an online nationwide population-based survey. Validated questionnaires were used to diagnose the disorders and measure quality of life. The change of clinical characteristics by addition of any comorbidity was analyzed using the Jonckheere-Terpstra trend test.

RESULTS

The prevalence rates of depression, migraine, insomnia, and fibromyalgia were 7.2 %, 5.6 %, 13.3 %, and 5.8 %, respectively. Among the 3030 included participants, 494 (16.3 %), 164 (5.4 %), 40 (1.3 %), and 6 (0.2 %) had one, two, three, and four of these conditions, respectively. The number of headache days per 30 days (Jonckheere-Terpstra trend test, p = 0.011) and migraine-related disability (migraine disability assessment score, p = 0.021) increased with an increase in the number of comorbidities but not with the intensity of headache (visual analog scale, p = 0.225) among participants with migraine. The severity of insomnia (Insomnia Severity Index, p < 0.001) and fibromyalgia (fibromyalgia severity score, p = 0.002) increased with additional comorbidities; however, depression (Patient Health Questionnaire-9, p = 0.384) did not show such an increase.

LIMITATIONS

The diagnoses of conditions were based on self-reported questionnaires.

CONCLUSIONS

The findings confirmed significant comorbidity between depression, migraine, insomnia, and fibromyalgia. Health professionals should be aware of the probable comorbidity of depression, migraine, insomnia, and fibromyalgia when caring for individuals with any of these four disorders.

The prevalence and clinical features of fibromyalgia in Chinese hospital patients with primary headache: The survey of fibromyalgia comorbid with headache

OBJECTIVE

The aims were to explore the prevalence and clinical features of fibromyalgia in Chinese hospital patients with primary headache.

BACKGROUND

Studies done in non-Chinese populations suggest that around one-third of patients with primary headache have fibromyalgia, but data from mainland China are limited. Investigations into the prevalence and clinical features of fibromyalgia in Chinese patients with primary headache would improve our understanding of these two complex disease areas and help guide future clinical practice.

METHODS

This cross-sectional study included adults with primary headache treated at 23 Chinese hospitals from September 2020 to May 2021. Fibromyalgia was diagnosed using the modified 2010 American College of Rheumatology criteria. Mood and insomnia were evaluated employing the Hospital Anxiety and Depression Scale and the Insomnia Severity Index.

RESULTS

A total of 2782 participants were analyzed. The fibromyalgia prevalence was 6.0% (166/2782; 95% confidence interval: 5.1%, 6.8%). Compared to primary headache patients without combined fibromyalgia, patients with primary headache combined with fibromyalgia were more likely to be older (47.8 vs. 41.7 years), women (83.7% [139/166] vs. 72.8% [1904/2616]), less educated (65.1% [108/166] vs. 45.2% [1183/2616]), and with longer-duration headache (10.0 vs. 8.0 years). Such patients were more likely to exhibit comorbid depression (34.3% [57/166] vs. 9.9% [260/2616]), anxiety (16.3% [27/166] vs. 2.7% [70/2612]), and insomnia (58.4% [97/166] vs. 17.1% [447/2616]). Fibromyalgia was more prevalent in those with chronic (rather than episodic) migraine (11.1% [46/414] vs. 4.4% [72/1653], p < 0.001) and chronic (rather than episodic) tension-type headache (11.5% [27/235] vs. 4.6% [19/409], p = 0.001). Most fibromyalgia pain was in the shoulders, neck, and upper back.

CONCLUSIONS

The prevalence of fibromyalgia in mainland Chinese patients with primary headache was 6.0%. Fibromyalgia was more common in those with chronic rather than episodic headache. The most common sites of fibromyalgia pain were the neck, shoulders, and back.

Impact of comorbid psychogenic non-epileptic seizures on migraine: An observational study

Objectives

There is a bidirectional and complex interplay between psychiatric comorbidities and migraine. Migraine has been observed in 50-60% of patients with psychogenic non-epileptic seizures (PNES). Studies describe migraine as a medical comorbidity in PNES. However, there are limited studies on impact of PNES on migraine. We aim to see the impact of PNES on migraine.

Materials and Methods

This cross-sectional and observational study was conducted at a tertiary-care center from June 2017 to May 2019. Fifty-two patients with migraine with PNES and 48 patients with migraine without PNES were included on the study. Migraine and PNES were diagnosed based on International Classification of Headache Disorders-3 (ICHD-3) and International League Against Epilepsy (ILAE) criteria, respectively. Headache intensity was assessed using visual analog scale. Comorbid depression, anxiety, and somatoform-symptom-disease were assessed using the Generalized Anxiety Disorder-7 Scale, Patient Health Questionnaire-9, and DSM-5 criteria, respectively.

Results

Females were common in both groups and the difference was statistically insignificant. Headache frequency was significantly more in patients with migraine with PNES (P < 0.05). However, headache intensity was similar in both groups. Patients with headaches and PNES identified triggers less commonly except for stress. Depression and somatoform symptom disorder were significantly more common in patients with migraine with PNES. Abnormal neurocircuitry involving frontal, limbic, and thalamic regions due to comorbid PNES may cause central sensitization, resulting in frequent migraine headaches which is further augmented by coexisting depression and somatoform-symptom-disease.

Conclusion

Migraine with PNES patients suffers more frequent headaches than patients with migraine without PNES. They differ in various headache triggers, with mental stress being the predominant trigger.

Migraine in the context of chronic primary pain, chronic overlapping pain disorders, and functional somatic disorders: A narrative review

OBJECTIVE

To contextualize migraine as the most common primary headache disorder in relation to other chronic primary pain and non-pain functional somatic and mental conditions.

BACKGROUND

Migraine is increasingly understood as a sensory processing disorder within a broader spectrum of symptom disorders. This has implications for diagnosis and treatment.

METHOD

Narrative review based on a search of the literature of the last 15 years on the overlap of migraine with other symptom disorders.

RESULTS

Migraine as the prototypical primary headache disorder not only comprises many non-headache symptoms in itself, it also shows high comorbidity with other chronic pain and non-pain conditions (e.g., fibromyalgia syndrome, irritable bowel syndrome, functional non-epileptic seizures, depression, anxiety, and posttraumatic stress disorder). Such "symptom disorders" share several etiological factors (e.g., female preponderance, psychological vulnerability) and psychophysiological mechanisms (e.g., altered sensory processing, pain expectancy). These facts are acknowledged by several recent integrative conceptualizations such as chronic primary pain, chronic overlapping pain conditions, or functional somatic disorders. Accordingly, migraine management increasingly addresses the total symptom burden and individual contributors to symptom experience, and thus incorporates centrally acting pharmacological and non-pharmacological, that is, psychological and behavioral, treatment approaches.

CONCLUSIONS

Migraine and also other primary headache disorders should be seen as particular phenotypes within a broader spectrum of symptom perception and processing disorders that require integrative diagnostics and treatment. A harmonization of classifications and better interdisciplinary collaboration are desirable.

A bibliometric analysis and visualization of tension-type headache

Background

Tension-type headache (TTH) is the most prevalent headache in the clinical practice, leading to impaired social activities, work-related disability, and heavy financial burdens. Previous studies have described possible inducement, potential pathophysiology, and clinical management of TTH; however, due to the lack of attention, literature involving bibliometric analysis is sporadic. Therefore, this study aimed to explore the current hotspots and future directions of the TTH field by bibliometric analysis.

Methods

By using CiteSpace and VOSviewer, literature regarding TTH between 2002 and 2021 from the Web of Science database was summarized and extracted. Annual publication trend, the most productive countries/regions and institutions, distribution of categories, co-citation of journals and references, and co-occurrence of keywords were analyzed.

Results

A total of 3,379 publications were included in the final visualization, indicating a stable trend in current research and a lack of breakthroughs over the past decades. These studies were mainly conducted in 120 countries/regions led by the United States and more than 600 institutions. Four eternal core themes were identified in TTH, including neurosciences, nursing, developmental psychology, and general/internal medicine. Cephalalgia ranked first, with the highest number of literature, and is the most influential journal in this area. Keyword analysis demonstrated that the similarities and differences between migraine and TTH, epidemiological studies, clinical double-blind trials, and potential populations have become key issues in the TTH field.

Conclusion

TTH has received less attention and breakthroughs in the past 20 years. To promote coordinated development between regions to fight headaches, cooperation and exchanges between countries and institutions are essential in the future. Relevant studies about headaches in children and adolescents, inducing factors such as emotional triggers and sleep disorders, concomitant diseases, possible pathogenesis, and headache treatments, are in the spotlight in recent years. This study offers a powerful roadmap for further research in this field.

Applying a biopsychosocial model to migraine: rationale and clinical implications

Migraine is a complex condition in which genetic predisposition interacts with other biological and environmental factors determining its course. A hyperresponsive brain cortex, peripheral and central alterations in pain processing, and comorbidities play a role from an individual biological standpoint. Besides, dysfunctional psychological mechanisms, social and lifestyle factors may intervene and impact on the clinical phenotype of the disease, promote its transformation from episodic into chronic migraine and may increase migraine-related disability.Thus, given the multifactorial origin of the condition, the application of a biopsychosocial approach in the management of migraine could favor therapeutic success. While in chronic pain conditions the biopsychosocial approach is already a mainstay of treatment, in migraine the biomedical approach is still dominant. It is instead advisable to carefully consider the individual with migraine as a whole, in order to plan a tailored treatment. In this review, we first reported an analytical and critical discussion of the biological, psychological, and social factors involved in migraine. Then, we addressed the management implications of the application of a biopsychosocial model discussing how the integration between non-pharmacological management and conventional biomedical treatment may provide advantages to migraine care.

Assessment of balance and functional capacity in fibromyalgia patients with and without migraine

ObjectiveTo evaluate the balance and functional capacity of fibromyalgia patients’ with and without migraine.MethodsObservational study with 60 women, between 20 and 60 years old (47±9 years), who were allocated into the following groups: 1. fibromyalgia and migraine (n=49); 2. only fibromyalgia (n=11). The following were used: Migraine Disability Assessment Test (MIDAS) to analyze the impact of migraine on quality of life; Revised Fibromyalgia Impact Questionnaire (FIQ-R) to assess the impact of fibromyalgia; six-minute walk test (6MWT)to assess functional capacity and Berg Balance Scale (BBE) for balance analysis.ResultsThere was no difference between groups 1 and 2 regarding functional capacity (TC6M: 308.7 m ±107.33 vs. 298.8 m ±153.54; p=0.55) and balance (BBE: 48± 14 vs. 47±16; p=0.68) as well as the impact on quality of life (FIQ: 78.8±14.77 vs. 74.4±13.99; p=0.28 and MIDAS: 31 ±24).ConclusionsOur study showed that there was no difference in functional capacity, balance and quality of life in fibromyalgia patients compared to patients with fibromyalgia associated with migraine.

The Frequency of Fibromyalgia in Migraine Patients

BACKGROUND: Fibromyalgia (FM) is a prevailing debilitating ailment that has been described in patients with migraines in several investigations. AIM: The study aimed to investigate the frequency of FM in migraine patients and to study the characteristics of migraine patients with comorbid FM. METHODS: This case–control study was piloted in the Neurology Unit, Department of Medicine in Ibn Sina Teaching Hospital in Mosul, Iraq, between March and November 2020. One hundred consecutive patients with migraine and 100 healthy controls were included in this study. The sociodemographic and headache characteristics of the patients were recorded. RESULTS: The frequency of FM was statistically higher among participants with migraines (27%) when compared to the controls (5%). Migraine patients with FM had a substantially older mean age and a higher ratio of female gender than migraine patients without FM. FM was found to be more common in patients without versus with aura. Patients with comorbid FM had greater headache frequency (p = 0.0002), headache intensity (p = 0.007), and higher scores on the “Headache Impact Test (HIT-6)” (p = 0.0001). CONCLUSIONS: There is a high frequency of FM in patients with migraines. Patients with coexistent “FM” and “migraine” tended to have more depressive symptoms, greater headache intensity, headache frequency, and when compared to healthy people, they are more likely to have a significant headache-related disability.

Patient Profiling Based on Spectral Clustering for an Enhanced Classification of Patients with Tension-Type Headache

Profiling groups of patients in clusters can provide meaningful insights into the features of the population, thus helping to identify people at risk of chronification and the development of specific therapeutic strategies. Our aim was to determine if spectral clustering is able to distinguish subgroups (clusters) of tension-type headache (TTH) patients, identify the profile of each group, and argue about potential different therapeutic interventions. A total of 208 patients (n = 208) with TTH participated. Headache intensity, frequency, and duration were collected with a 4-week diary. Anxiety and depressive levels, headache-related burden, sleep quality, health-related quality of life, pressure pain thresholds (PPTs), dynamic pressure thresholds (DPT) and evoked-pain, and the number of trigger points (TrPs) were evaluated. Spectral clustering was used to identify clusters of patients without any previous assumption. A total of three clusters of patients based on a main difference on headache frequency were identified: one cluster including patients with chronic TTH (cluster 2) and two clusters including patients with episodic TTH (clusters 0–1). Patients in cluster 2 showed worse scores in all outcomes than those in clusters 0–1. A subgroup of patients with episodic TTH exhibited pressure pain hypersensitivity (cluster 0) similarly to those with chronic TTH (cluster 2). Spectral clustering was able to confirm subgrouping of patients with TTH by headache frequency and to identify a group of patients with episodic TTH with higher sensitization, which may need particular attention and specific therapeutic programs for avoiding potential chronification.

OnabotulinumtoxinA Is an Effective Treatment for Chronic Migraine in Patients With Comorbid Fibromyalgia

Introduction: Fibromyalgia (FM) is a frequent comorbidity in patients with chronic migraine (CM). PREEMPT trials, which demonstrated the efficacy of OnabotulinumtoxinA (OnabotA) on CM, excluded patients with FM. Our aim was to evaluate the effectiveness of OnabotA in a series of patients with CM and FM.

Methods: We analyzed patients with a previous diagnosis of CM and FM who had received sessions of OnabotA quarterly between January 2014 and January 2020 in a specialized Headache Clinic. Primary endpoint was the reduction in moderate to severe headache days at 3, 6, 9, and 12 months.

Results: Data were collected from 31 patients with CM and FM that received OnabotA (100% females). Mean age at first procedure was 50.2 ± 11.3 years. Depression (93.5%), other central sensitization syndromes (irritable bowel syndrome, interstitial cystitis, multiple chemical sensitivity, endometriosis, and chronic fatigue syndrome) (48.4%), and medication overuse headache (90.3%) were frequent comorbidities. 48.4% of patients had failed ≥3 preventives previously. The percentage of patients who achieved ≥30 and ≥50% moderate-severe headache reduction on the third month was 65.4 and 48.2%, respectively. Twenty-three patients completed four cycles of treatment, with 13.4 fewer headache days per month than at baseline (p < 0.001). By 1 year, 69.5% had ≥50% reduction of headache frequency and 39.1% had a ≥75% reduction. In 4 cases (21%), OnabotA was interrupted due to a lack of response. Only mild adverse effects were recorded.

Conclusion: OnabotA is an effective treatment for CM in patients with FM.

Lasmiditan in patients with common migraine comorbidities: a post hoc efficacy and safety analysis of two phase 3 randomized clinical trials

OBJECTIVE

Determine whether common migraine comorbidities affect the efficacy and safety of lasmiditan, a 5-HT_1F receptor agonist approved in the United States for the acute treatment of migraine.

METHODS

In SPARTAN and SAMURAI (double-blind Phase 3 clinical trials), patients with migraine were randomized to oral lasmiditan 50 mg (SPARTAN only), 100mg, 200 mg, or placebo. Lasmiditan increased the proportion of pain-free and most bothersome symptom (MBS)-free patients at 2 h after dose compared with placebo. Most common treatment-emergent adverse events (TEAEs) were dizziness, paraesthesia, somnolence, fatigue, nausea, muscular weakness, and hypoesthesia. Based upon literature review of common migraine comorbidities, Anxiety, Allergy, Bronchial, Cardiac, Depression, Fatigue, Gastrointestinal, Hormonal, Musculoskeletal/Pain, Neurological, Obesity, Sleep, and Vascular Comorbidity Groups were created. Using pooled results, efficacy and TEAEs were assessed to compare patients with or without a given common migraine comorbidity. To compare treatment groups, p-values were calculated for treatment-by-subgroup interaction, based on logistic regression with treatment-by-comorbidity condition status (Yes/No) as the interaction term; study, treatment group, and comorbidity condition status (Yes/No) were covariates. Differential treatment effect based upon comorbidity status was also examined. Trial registration at clinicaltrials.gov: SAMURAI (NCT02439320) and SPARTAN (NCT02605174).

RESULTS

Across all the Comorbidity Groups, with the potential exception of fatigue, treatment-by-subgroup interaction analyses did not provide evidence of a lasmiditan-driven lasmiditan versus placebo differential treatment effect dependent on Yes versus No comorbidity subgroup for either efficacy or TEAE assessments.

CONCLUSIONS

The efficacy and safety of lasmiditan for treatment of individual migraine attacks appear to be independent of comorbid conditions.

Hyperalgesia and Central Sensitization Signs in Patients with Cluster Headache: A Cross-Sectional Study

OBJECTIVE

To investigate central sensitization (CS) in cluster headache (CH) and to evaluate its relationship with disease characteristics and psychological comorbidities.

DESIGN

Cross-sectional study.

SETTINGS

Whether CS occurs in CH, as it does in other primary headaches, is a subject of debate. Few studies have evaluated the presence of CS and its relationship with psychological comorbidities in patients with CH.

SUBJECTS

Twenty patients with episodic or chronic CH and 16 healthy controls were recruited.

METHODS

The variables evaluated included frequency, intensity and duration of headache attacks, pressure pain thresholds (PPTs) and wind-up (WU) ratios of pain bilaterally measured over trigeminal and extratrigeminal areas, and results of questionnaires regarding anxiety and depression (Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory [BDI], State-Trait Anxiety Inventory [STAI]), quality of life (Short Form-36 [SF-36]), headache impact (Headache Impact Test [HIT-6]), and allodynia (Allodynia Symptom Checklist [ASC]).

RESULTS

PPT levels were significantly lower in the CH group compared with the healthy participants (all tested points, P < 0.001). No differences were found in WU ratios between groups. However, differences in HADS (P < 0.01), BDI (P < 0.01), STAI (P < 0.01), SF-36 (P < 0.01), HIT-6 (P < 0.001), and ASC (P < 0.01) were observed between groups. The healthy group showed a moderate negative correlation between SF-36 and BDI (rho = -0.59, P = 0.03). Likewise, the CH group showed a moderate negative correlation between frequency and BDI (rho = -0.52, P = 0.03), a strong positive correlation between duration and HADS (rho = 0.86, P < 0.01), and a moderate negative correlation between intensity and PPT over symptomatic V1 (rho = -0.66, P < 0.01) and over asymptomatic V1 (rho = -0.65, P < 0.01). The CH group also showed a moderate negative correlation between SF-36 and anxiety and depression variables.

CONCLUSIONS

Our findings show that patients with CH have lower PPT levels at cranial and extracranial points, suggesting, as in other primary headaches, the presence of CS. We have also found a high prevalence of psychiatric comorbidities that correlate with the length and frequency of attacks. These findings highlight the importance of a multidisciplinary approach to the treatment of patients with CH.

Peripheral and central nervous system correlates in fibromyalgia

BACKGROUND

Fibromyalgia (FM) is a syndrome characterized by altered pain processing at central and peripheral level, whose pathophysiologic mechanisms remain obscure. We aimed at exploring the structural changes of peripheral nociceptor measured by skin biopsy, the functional changes of central nociceptive pathway assessed by laser-evoked potentials (LEP), and their correlation with clinical features and comorbidities.

METHODS

In all, 81 patients diagnosed with FM underwent skin biopsies with quantification of intraepidermal nerve fibre density (IENFD) at the thigh and distal leg, and LEP recording by stimulating hand, thigh and foot. Nerve conduction study (NCS), clinical features, comorbidity with migraine and mood disorders, and previous, non-active immune-mediated disorders were recorded.

RESULTS

Intraepidermal nerve fibre density was reduced in 85% of patients at the thigh and in 12.3% of patients at the distal leg, whereas it was normal in 14.8% of patients. N2P2 habituation index from laser stimulation at the thigh was altered in 97.5% of patients and correlated with reduced IENFD at the thigh. LEP latencies and amplitudes did not differ among groups. No association was found between IENFD, LEP, clinical features and comorbidities.

CONCLUSIONS

Fibromyalgia patients most commonly showed a mild loss of peripheral nociceptors at the thigh rather than distal small fibre neuropathy. This finding was associated with an altered habituation index and strengthened the hypothesis that central sensitization plays a key role in the pathogenesis of the disease.

SIGNIFICANCE

Central impairment of pain processing likely underlies FM, which in most patients is associated with mild proximal small fibre pathology.

Validity and Reliability of the Fibromyalgia Rapid Screening Tool Among Individuals with Chronic Daily Headache: A Clinic-Based Study

BACKGROUND

Fibromyalgia is a common chronic pain disorder typically associated with headache disorders, particularly chronic daily headache. However, fibromyalgia is typically underdiagnosed and undertreated. The Fibromyalgia Rapid Screening Tool questionnaire is a brief, self-administered questionnaire composed of six "yes/no" questions for detecting fibromyalgia. The Fibromyalgia Rapid Screening Tool questionnaire has demonstrated high sensitivity and specificity among patients with chronic diffuse pain conditions. This study assessed the validity and reliability of the aforementioned questionnaire for detecting fibromyalgia among patients with chronic daily headache.

METHODS

Consecutive first-visit headache patients with primary chronic daily headache (≥15 days/month for three or more months) at the outpatient clinics of four university hospitals were enrolled in this study from April 2015 to October 2015, and the validity and reliability of the Fibromyalgia Rapid Screening Tool questionnaire for determining fibromyalgia were evaluated. Fibromyalgia was diagnosed according to the American College of Rheumatology criteria of 2010.

RESULTS

A total of 171 patients with primary chronic daily headache were recruited, and 100 (58.4%) were determined to have fibromyalgia. Receiver operating characteristic curve analysis revealed that a cutoff score of 5 (corresponding to the number of positive items) provided the highest rate of correct identification of patients (77.2%), with a sensitivity of 70.0% and specificity of 87.3%. The positive and negative predictive values were 88.6% and 67.4%, respectively. The Cronbach's alpha coefficient was 0.684.

CONCLUSIONS

The Fibromyalgia Rapid Screening Tool is a valid and reliable instrument for identifying fibromyalgia among patients with chronic daily headache.

A Systematic Review of Studies Using the Multidimensional Assessment of Fatigue Scale

PURPOSE

To review how the Multidimensional Assessment of Fatigue (MAF) has been used and evaluate its psychometric properties.

METHODS

We conducted a database search using "multidimensional assessment of fatigue" or "MAF" as key terms from 1993 to 2015, and located 102 studies.

RESULTS

Eighty-three were empirical studies and 19 were reviews/evaluations. Research was conducted in 17 countries; 32 diseases were represented. Nine language versions of the MAF were used. The mean of the Global Fatigue Index ranged from 10.9 to 49.4. The MAF was reported to be easy-to-use, had strong reliability and validity, and was used in populations who spoke languages other than English.

CONCLUSION

The MAF is an acceptable assessment tool to measure fatigue and intervention effectiveness in various languages, diseases, and settings across the world.

Fibromyalgia in migraine: a retrospective cohort study

Background

Migraine is a common and disabling disorder. Fibromyalgia has been shown to be commonly comorbid in patients with migraine and can intensify disability. The aim of this study was to determine if patients with co-morbid fibromyalgia and migraine report more depressive symptoms, have more headache related disability, or report higher intensity of headache as compared to patients with migraine only. Cases of comorbid fibromyalgia and migraine were identified using a prospectively maintained headache database at Mayo Clinic Rochester. One-hundred and fifty seven cases and 471 controls were identified using this database and the Mayo Clinic electronic medical record.

Findings

Depressive symptoms as assessed by PHQ-9, intensity of headache, and migraine related disability as assessed by MIDAS were primary measures used to compare migraine patients with comorbid fibromyalgia versus those without. Patients with comorbid fibromyalgia reported significantly higher PHQ-9 scores (OR 1.08, p < .0001) and headache intensity scores (OR 1.149, p = .007). There was no significant difference in migraine related disability (OR 1.002, p = .075). Patients with fibromyalgia were more likely to score in a higher category of depression severity (OR 1.467, p < .0001) and more likely to score in a higher category of migraine related disability (OR 1.23, p = .004).

Conclusion

Patients with comorbid fibromyalgia and migraine report more depressive symptoms, higher headache intensity, and are more likely to have severe headache related disability as compared to controls without fibromyalgia. Clinicians who care for patients with migraine may consider screening for comorbid fibromyalgia particularly in patients with moderate to severe depressive symptoms, high headache intensity and/or high headache related disability. This is the first matched study to look at these characterisitcs, and it replicates previous findings from unmatched studies.

Nociceptive blink reflex habituation biofeedback in migraine

Reduced habituation of the nociceptive blink reflex (NBR) is considered a trait marker for genetic predisposition to migraine. In this open-label randomized controlled study, we aimed to test the efficacy of a biofeedback training based on learning of habituation of the NBR (NBR biofeedback) compared with pharmacological (topiramate) treatment and NBR biofeedback plus topiramate treatment in a cohort of migraine without aura patients eligible for prophylaxis. Thirty-three migraine patients were randomly assigned to three months of treatment with: 1) NBR biofeedback, 2) NBR biofeedback plus topiramate 50 mg (b.i.d.), or 3) topiramate 50 mg (b.i.d.). Frequency of headache and disability changes were the main study outcomes. Anxiety, depression, sleep, fatigue, quality of life, allodynia and pericranial tenderness were also evaluated. NBR biofeedback reduced the R2 area, without improving R2 habituation. However, it reduced the frequency of headache and disability, similarly to the combined treatment and topiramate alone. Reduced habituation of the NBR is a stable neurophysiological pattern, scarcely modifiable by learning procedures. Training methods able to act on stress-related responses may modulate cortical mechanisms inducing migraine onset and trigeminal activation under stressful trigger factors.

The Impact of Fibromyalgia on Disability, Anxiety, Depression, Sleep Disturbance, and Quality of Life in Patients with Migraine

Introduction

The aim of the present study was to assess the impact of fibromyalgia (FM) comorbidity on disability, anxiety, depression, sleep disturbance, and quality of life in patients with migraine.

Methods

Eighty-six consecutive migraine patients (age, 35.4±10.3 years; 69 women and 17 men) were enrolled in the study. The headache characteristics of the patients were recorded. FM was diagnosed based on the 1990 American College of Rheumatology classification criteria for the diagnosis of FM. All patients were asked to complete selfreport questionnaires, including the Fibromyalgia Impact Questionnaire (FIQ), Headache Impact Test (HIT-6), Migraine Disability Assessment Questionnaire (MIDAS), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the 36- Item Short Form Survey (SF-36) to assess their pain-related disability, migraine-related disability, depression, anxiety, sleep disturbance, and quality of life.

Results

Of the migraine patients, 28 (32.6%) met the criteria for FM. Migraine patients with FM showed significantly increased migraine frequency and BDI, BAI, and PSQI scores and decreased quality of life scores for all eight domains of the SF-36 compared to patients with migraine alone, whereas the mean HIT-6 and MIDAS values did not differ between the groups. FIQ score showed statistically significant positive correlations with BDI, BAI, PSQI, and MIDAS scores and with headache frequency (p<0.001, r=0.657; p<0.001, r=0.730; p<0.001, r=0.754; p=0.005, r=0.300; p=0.008, r=0.286, respectively); FIQ score showed negative correlations with scores for all domains of the SF-36. In multivariate linear regression analysis, BDI, BAI, and PSQI scores independently predicted FIQ score.

Conclusion

Our study results demonstrate the significant impact of FM comorbidity on anxiety, depression, sleep disturbance, and quality of life in this population. FM evaluation and treatment should be considered in the routine care of patients with migraine to globally improve the patient's quality of life.

Increased pain sensitivity in migraine and tension-type headache coexistent with low back pain: A cross-sectional population study

BACKGROUND

Low back pain is common in the general population and in individuals with primary headaches. We assessed the relative frequency of self-reported back pain in persons with and without primary headaches and examined pain sensitivity.

METHOD

A population of 796 individuals completed a headache interview based on ICHD criteria and provided data of interest in a self-administered questionnaire. Headache cases were classified into chronic (≥15) (CH) or episodic (<15 headache days/month) (EH). A total of 495 had a pericranial total tenderness score (TTS), and 494 had cephalic and extracephalic pressure pain thresholds (PPTs) assessed.

RESULTS

Adjusted for age, gender, education and poor self-rated health, 1-year relative frequency of back pain was higher in individuals with CH (82.5%) and EH (80.1%) compared to no headache group (65.7%). In persons with back pain, TTS was higher in CH, (26.3 ± 12.1) than in EH, (18.5 ± 10.0; p < 0.001) and higher in both groups than in those with no headache, 10.8 ± 8.5 (p < 0.001 and p < 0.001, respectively). In persons with back pain, temporalis PPT were lower in CH, 169.3 ± 57.8, than in EH, 225.2 ± 98.1, and in no headache group, 244.3 ± 105.4 (p = 0.02 and p = 0.01, respectively). In persons with back pain, finger PPT were lower in CH, 237.1 ± 106.7, than in EH, 291.3 ± 141.3, or in no headache group, 304.3 ± 137.4 (p = 0.02 and p < 0.001, respectively).

CONCLUSION

Back pain is highly frequent in individuals with CH, followed by EH and no headache. In persons with CH, back pain is associated with lower cephalic and extracephalic PPTs suggesting central sensitization may be a substrate or consequence of comorbidity.

SIGNIFICANCE

We found that back pain has high relative frequency in individuals with CH followed EH and no headache. Back pain is associated with low cephalic and extracephalic PPTs in individuals with CH. Central sensitization may be a substrate or consequence of this comorbidity of back pain and CH.

Characterization of migraineurs presenting interictal widespread pressure hyperalgesia identified using a tender point count: a cross-sectional study

BACKGROUND

Migraineurs exhibit pain hypersensitivity throughout the body during and between migraine headaches. Migraine is classified as a central sensitivity syndrome, typified by fibromyalgia showing widespread pressure hyperalgesia determined by a tender point. This study was performed to examine whether: 1) there is a subgroup of episodic migraineurs with widespread pressure hyperalgesia during and between attacks; 2) if such a subgroup exists, what is the prevalence and what is the difference between groups with interictal widespread hyperalgesia and acute allodynia regarding the demographic and clinical characteristics of migraine.

METHODS

This was a cross-sectional study. A total of 176 consecutive episodic migraineurs and 132 age- and sex-matched controls were recruited. The presence of widespread pressure hyperalgesia was investigated using manual tender point survey. To classify a subject's response as widespread pressure hyperalgesia, the cutoff value for responders was defined as the positive tender point count below which 95% of controls responded.

RESULTS

Based on the number of positive tender points in controls, the cutoff value of tender point count for pressure hyperalgesia responders was 7. Of the 176 subjects, interictal widespread pressure hyperalgesia and acute allodynia were observed in 74 (42%) and 115 (65.3%) patients, respectively. Univariate analysis indicated that risk factors associated with interictal widespread pressure hyperalgesia were female gender, younger age at migraine onset, higher frequency of migraine attacks, severe headache impact, cutaneous allodynia and depression. Multivariate logistic regression analysis confirmed that independent risk factors associated with interictal widespread pressure hyperalgesia were female gender, higher frequency of migraine attack and younger age at onset.

CONCLUSION

Interictal widespread pressure hyperalgesia was common (42%) in the episodic migraineurs and was associated with younger age at onset, female gender, and higher frequency of headache, but not duration of migraine illness. Presence of interictal widespread pressure hyperalgesia is assumed to be an indicator of genetic susceptibility to migraine attacks. We expect that a tender point count, as an alternative to quantitative sensory testing, will become useful as a diagnostic indicator of interictal hyperalgesia in migraineurs to predict susceptibility to migraine attacks and to permit tailored treatment.

Salivary glutamate is elevated in individuals with chronic migraine

Background

Glutamate has been implicated in migraine pathogenesis, and is elevated in the plasma, cerebrospinal fluid, and saliva in migraineurs. However, no comparison of glutamate levels among chronic migraine, episodic migraine and controls has been reported. The aim is to compare salivary glutamate levels of individuals with chronic migraine with those of individuals with episodic migraine and healthy controls.

Methods

We investigated salivary glutamate level of 46 women with chronic migraine, 50 women with episodic migraine, and 19 healthy controls via enzyme linked immunosorbent assay.

Results

The salivary glutamate level of the chronic migraine group (median and interquartile range, 20.47 [15.27–30.15] pmol/mg total protein) was significantly higher than those of the episodic migraine (16.17 [12.81–20.15] pmol/mg total protein, p = 0.008) and control (12.18 [9.40–16.24] pmol/mg total protein, p = 0.001) groups. The salivary glutamate level of the episodic migraine group was marginally elevated from that of the control group (post hoc p = 0.016). Thresholds of 16.58 and 17.94 pmol/mg total protein optimize the sensitivity and specificity to differentiate chronic migraine participants from healthy controls and episodic migraine participants, respectively.

Conclusions

Salivary glutamate level was elevated in chronic migraine participants. These data suggest that salivary glutamate level could be an indicator of CM

Mental Status as a Common Factor for Masticatory Muscle Pain: A Systematic Review

Masticatory muscle pain (MMP) is the primary reason for chronic non-odontogenic orofacial pain in the human population. MMP has become a considerable social problem, which affects about 12-14% of the adult population and is 1.5-2 times more frequent in women than in men. This term defines a pain which has its origins in the masticatory muscles. Although MMP is typically felt in the face, jaws, and preauricular area, MMP can radiate to the ear, teeth, head, and neck. This systematic review explains the relationship between MMP and common mental states, such as anxiety, depression, mood and stress-related disorders, and is reported in accordance with PRISMA guidelines. We performed a search in the PubMed database for peer-reviewed articles published after November 1st 2006 in the context of MMP and mental states. According to the defined criteria, 38 studies were finally included into the systematic review, of which prospective cohort studies were found to be the most common. We investigated four primary outcomes (anxiety, depression, mood disorders, and stress-related disorders) and several secondary outcomes of search. Seventy-nine percent of studies concerned depression, 42% anxiety, 29% mood disorders, and 21% stress-related disorders. Most of the studies showed a relationship between MMP and alterations in mental status. Nonetheless, the researchers usually evidenced only the co-occurrence of psychiatric disorders and dysfunctions of the masticatory muscles among the group of patients, in large part in women. Moreover, some studies were marked with limited generalizability of the reported results, quality flaws and heterogeneity. In the light of the analyzed literature, the causal relationship between mental states and MMP is still not clearly established.

Identification of subgroups of patients with tension type headache with higher widespread pressure pain hyperalgesia

Background

Identification of subgroups of patients with different levels of sensitization and clinical features can help to identify groups at risk and the development of better therapeutic strategies. The aim of this study was to identify subgroups of patients with tension type headache (TTH) with different levels of sensitization, clinical pain features, and psychological outcomes.

Methods

A total of 197 individuals with TTH participated. Headache intensity, frequency, and duration and medication intake were collected with a 4-weeks diary. Pressure pain thresholds were assessed bilaterally over the temporalis muscle, C5-C6 joint, second metacarpal and tibialis anterior muscle to determine widespread pressure pain hyperalgesia. The Hospital Anxiety and Depression Scale assessed anxiety and depression. The State-Trait Anxiety Inventory evaluated the state and trait levels of anxiety. The Headache Disability Inventory evaluated the burden of headache. Health-related quality of life was determined with the SF-36 questionnaire. Groups were considered as positive (three or more criteria) or negative (less than three criteria) on a clinical prediction rule: headache duration <8.5 h/day; headache frequency <5.5 days/week; bodily pain <47 and vitality <47.5.

Results

The ANCOVA revealed that subjects in group 1 (positive rule, n = 89) exhibited longer headache history, shorter headache duration, lower headache frequency, higher widespread pressure hyperalgesia, higher anxiety trait levels, and lower quality of life (all, P < 0.01) than those subjects within group 2 (negative rule, n = 108). Differences were similar between men and women.

Conclusions

This study identified a subgroup of patients with TTH with higher sensitization, higher chronicity of headaches and worse quality of life but lower frequency and duration of headache episodes. This subgroup of individuals with TTH may need particular attention and specific therapeutic programs for avoiding potential chronification.

Comorbidity in Migraine with Functional Somatic Syndromes, Psychiatric Disorders and Inflammatory Diseases: A Matter of Central Sensitization?

To approach the questions as to why migraine appears to be associated with functional somatic syndromes (FSSs) and whether central sensitization may be an underlying mechanism, the present study investigated (a) comorbidity with diagnoses of three FSSs, three psychiatric disorders, and three inflammatory diseases, (b) degree of mental health problems (stress, burnout, anxiety, depression and somatization), and (c) prevalence of ten cognitive/affective and nine airway symptoms in persons with migraine in the general population. From a randomized and stratified Swedish adult sample, questionnaire data were analyzed from 151 individuals with a diagnosis of migraine and 3,255 without migraine. The results showed (a) significant comorbidity in migraine with all FSSs, psychiatric disorders and inflammatory diseases, (b) significantly elevated scores on stress, burnout, anxiety, depression, and somatization, and (c) relatively high prevalence rates on almost all symptoms. Taken together, the results motivate future study of central sensitization as a mechanism underlying migraine.

Effects of OnabotulintoxinA on Habituation of Laser Evoked Responses in Chronic Migraine

Onabotulintoxin A (BontA) is an efficacious preventive treatment for chronic migraine, though the specific mechanism of action is still under discussion. The study aims: (1) To evaluate pain processing modifications in chronic migraine patients (CM) under single BontA administration in pericranial muscles, by means of CO² Laser Evoked Potentials (LEPs) obtained by the stimulation of the skin over the right frontal and trapezius injection sites and hand dorsum, in a double blind placebo controlled crossover design. (2) To correlate main LEPs findings with clinical outcome after one year of BontA treatment. Twenty refractory CM patients were included in the analysis. The LEPs were recorded in basal conditions and seven days after BontA (PREEMPT protocol) and saline solution injection. The N1, N2 and P2 amplitude and latencies and N2P2 habituation index were evaluated and correlated with the percent change of headache frequency after one year of toxin treatment. After seven days of BontA treatment, a normalization of the trigeminal habituation index was observed, which was correlated with the clinical outcome after one year of BontA therapy. Patients displaying trigeminal LEPs facilitation at T0 time showed a more efficient therapeutic outcome. Neurotoxin may exert a modulating effect on trigeminal nociception, normalizing central neurotransmission.

Considerations for management of migraine symptoms in the primary care setting

Migraine is a common disabling brain disorder that affects one in seven US citizens annually. The burden of migraine is substantial, both in economic terms and for individual patients and their close family members. Initial medical consultations for migraine are usually with a primary care physician (PCP), and it is predominantly managed in a primary care setting; therefore, PCPs need a thorough understanding of migraine and the treatment options. This review provides an overview of the prevalence, symptoms, burden, and diagnosis of migraine with a focus on adults. Important aspects of migraine management, such as medication overuse and chronic migraine, are highlighted and insight is provided into factors for consideration when prescribing acute/abortive treatment for migraine to ensure that individual patients receive optimal pharmaceutical management. The effects of associated symptoms, e.g. nausea/vomiting, on treatment efficacy are pertinent in migraine; however, many therapy options, including alternative delivery systems, are available, thus facilitating the selection of optimal treatment for an individual patient.

Impact of migraine on fibromyalgia symptoms

BACKGROUND

Fibromyalgia (FMS) and high frequency episodic/chronic migraine (M) very frequently co-occur, suggesting common pathophysiological mechanisms; both conditions display generalized somatic hyperalgesia. In FMS-M comorbidity we assessed if: a different level of hyperalgesia is present compared to one condition only; hyperalgesia is a function of migraine frequency; migraine attacks trigger FMS symptoms.

METHODS

Female patients with fibromyalgia (FMS)(n.40), high frequency episodic migraine (M1)(n.41), chronic migraine (M2)(n.40), FMS + M1 (n.42) and FMS + M2 (n.40) underwent recording of: -electrical pain thresholds in skin, subcutis and muscle and pressure pain thresholds in control sites, -pressure pain thresholds in tender points (TePs), -number of monthly migraine attacks and fibromyalgia flares (3-month diary). Migraine and FMS parameters were evaluated before and after migraine prophylaxis, or no prophylaxis, for 3 months with calcium-channel blockers, in two further FMS + H1 groups (n.49, n.39). 1-way ANOVA was applied to test trends among groups, Student's t-test for paired samples was used to compare pre and post-treatment values.

RESULTS

The lowest electrical and pressure thresholds at all sites and tissues were found in FMS + M2, followed by FMS + H1, FMS, M2 and M1 (trend: p < 0.0001). FMS monthly flares were progressively higher in FMS, FMS + M1 and FMS + M2 (p < 0.0001); most flares (86-87 %) occurred within 12 h from a migraine attack in co-morbid patients (p < 0.0001). Effective migraine prophylaxis vs no prophylaxis also produced a significant improvement of FMS symptoms (decreased monthly flares, increased pain thresholds)(0.0001 < p < 0.003).

CONCLUSIONS

Co-morbidity between fibromyalgia and migraine involves heightened somatic hyperalgesia compared to one condition only. Increased migraine frequency - with shift towards chronicity - enhances both hyperalgesia and spontaneous FMS pain, which is reversed by effective migraine prophylaxis. These results suggest different levels of central sensitization in patients with migraine, fibromyalgia or both conditions and a role for migraine as a triggering factor for FMS.

Patients with psychogenic nonepileptic seizures report more severe migraine than patients with epilepsy

PURPOSE

Clinical observations suggest that psychogenic non-epileptic seizure (PNES) patients often have severe migraine, more severe than epilepsy patients. Investigations into migraine characteristics in patients with PNES are lacking. In this study we tested the hypothesis that, compared to epilepsy patients, PNES patients have more severe migraine, with more frequent and longer duration attacks that cause greater disability.

METHOD

In this observational study, 633 patients with video-EEG proven epilepsy or PNES were identified from the Mayo Clinic Epilepsy Monitoring Unit database. Contacted patients were screened for migraine via a validated questionnaire, and when present, data regarding migraine characteristics were collected. Two-sample t-tests, chi square analyses, and Mann-Whitney U tests were used to compare migraine characteristics in PNES patients to those of epilepsy patients.

RESULTS

Data from 43 PNES patients with migraine and 29 epilepsy patients with migraine were available. Compared to epilepsy patients, PNES patients reported having more frequent headaches (mean 15.1 ± 9.8 vs. 8.1 ± 6.6 headache days/month, p<.001), more frequent migraine attacks (mean 6.5 ± 6.3 vs. 3.8. ± 4.1 migraines/month, p=.028), longer duration migraines (mean 39.5 ± 28.3 vs. 27.3 ± 20.1h, p=.035), and more frequently had non-visual migraine auras (78.6% vs. 46.7% of patients with migraine auras, p=.033). Migraine-related disability scores were not different between PNES and epilepsy patients (median 39, interquartile range 89 vs. 25, interquartile range 60.6, p=.15).

CONCLUSION

Compared to epilepsy patients with migraine, PNES patients with migraine report having a more severe form of migraine with more frequent and longer duration attacks that are more commonly associated with non-visual migraine auras.

Factors associated with disability and impact of tension-type headache: findings of the Korean headache survey

BACKGROUND

Although mostly mild in symptom severity, tension-type headache (TTH) can cause disability. However, factors associated with disability of TTH have been rarely reported. This study sought to assess the factors associated with TTH-related disability and impact.

METHODS

We analyzed data form the Korean Headache Survey, a nation-wide survey regarding headache in all Korean adults aged 19-69 years. TTH-related disability was measured by surveying actual disability and Headache Impact Test-6 (HIT-6). Actual disability was defined as having one or more days of activity restriction or missed activity due to headache in the last 3 months. The HIT-6 score ≥ 50 was regarded as significant headache impact associated with TTH. We assessed factors associated with TTH-related disability and impact using logistic regression analyses adjusting for sociodemographic variables and headache characteristics.

RESULTS

Among 1507 individuals, the 1-year prevalence rate of TTH was 30.7% (n = 463), of which 4.8% reported actual disability and 21.3% had headache impact, respectively. In univariate analyses, sociodemographic variables were not associated with actual disability and headache impact, respectively. There were relationships between several headache characteristics and actual disability/headache impact. After adjustment of potential confounders, moderate headache intensity was correlated with actual disability (odds ratio [OR]: 4.41, 95% confidence interval [CI]: 1.46-13.27), while an inverse association was observed between no aggravation by routine activity and actual disability (OR: 0.32, 95% CI: 0.12-0.88). Multivariate analyses showed that ORs for headache impact were increased in those with higher headache frequency (OR: 2.54, 95% CI: 1.47-4.39 for 1-14 days/month; OR: 23.83, 95% CI: 5.46-104.03 for ≥ 15 days/month), longer headache time duration (OR: 1.84, 95% CI: 1.04-3.25 for ≥ 1 and < 4 hours; OR: 2.44 95% CI: 1.17-5.11 for ≥ 4 hours), and phonophobia (OR: 1.73, 95% CI: 1.02-2.95), whereas decreased in those with no aggravation by routine activity (OR: 0.32, 95% CI: 0.12-0.88).

CONCLUSIONS

Several headache characteristics were associated with actual disability and headache impact among TTH individuals. Our findings suggest that there needs to be consideration careful of troublesome headache characteristics for TTH individuals suffering from disability and impact.

Headache and migraine: a leading cause of absenteeism

Migraine and tension-type headache, the two dominant primary headache disorders, are among the most common causes of lost work time. The population impact of both disorders is similar, but the demographics and individual impact differ. Approximately 18% of females and 6% of males have migraine in the general population. Prevalence is highest around age 40, when individuals are at the peak of their work abilities. Headaches cause substantial individual impact on work productivity and employer and societal burden from direct medical costs, lost work time, and underemployment, and, in more severe persistent headache, unemployment. The lost work time costs greatly exceed medical care costs. Chronic daily headache (15 or more headache days per month) represents a widely accepted stage of pain progression that occurs in 2-4% of the population. Treatment of headaches can be acute or preventive. The goals of acute treatment are timely alleviation of pain and associated symptoms without recurrence, the restoring of ability to function, minimizing the use of back-up and rescue medications with minimal adverse events, and providing the best cost-effective management. Migraine-preventive medications are used to decrease future attack frequency, severity, and duration, improving responsiveness to acute treatments, and improving overall function and decreasing disability. Preventing analgesic overuse that leads to chronic daily headache is another goal of using preventive treatment. Preventive medications should be considered in migraine patients reporting either 3-6 or more headache days per month, depending on how headaches impair function.

Sleep features and central sensitization symptoms in primary headache patients

BACKGROUND

Association between sleep disorders and headache is largely known. The aim of the present study was to evaluate sleep quality and quantity in a large cohort of primary headache patients, in order to correlate these scores with symptoms of central sensitization as allodynia, pericranial tenderness and comorbidity with diffuse muscle-skeletal pain.

METHODS

One thousand six hundreds and seventy primary headache out patients were submitted to the Medical Outcomes Study (MOS) within a clinical assessment, consisting of evaluation of frequency of headache, pericranial tenderness, allodynia and coexistence of fibromyalgia syndrome (FM).

RESULTS

Ten groups of primary headache patients were individuated, including patients with episodic and chronic migraine and tension type headache, mixed forms, cluster headache and other trigeminal autonomic cephalalgias. Duration but not sleep disturbances score was correlated with symptoms of central sensitization as allodynia and pericranial tenderness in primary headache patients. The association among allodynia, pericranial tenderness and short sleep characterized chronic migraine more than any other primary headache form. Patients presenting with FM comorbidity suffered from sleep disturbances in addition to reduction of sleep duration.

CONCLUSION

Self reported duration of sleep seems a useful index to be correlated with allodynia, pericranial tenderness and chronic headache as a therapeutic target to be assessed in forthcoming studies aiming to prevent central sensitization symptoms development.

The role of vitamin D in pathophysiology and treatment of fibromyalgia

Recent studies showed that most cells have receptors and enzymes responsible for metabolism of vitamin D. Several diseases have been linked to vitamin D deficiency, such as hypertension, diabetes, depression, Alzheimer's disease, Parkinson's disease, multiple sclerosis, and chronic pain syndromes such as fibromyalgia. The association between fibromyalgia and vitamin D deficiency is very controversial in the literature with conflicting studies and methodological problems, which leads to more questions than answers. The purpose of this article is to raise questions about the association of hypovitaminosis D with fibromyalgia considering causal relationships, treatment, and pathophysiological explanations.

Worldwide epidemiology of fibromyalgia

Studying the epidemiology of fibromyalgia (FM) is very important to understand the impact of this disorder on persons, families and society. The recent modified 2010 classification criteria of the American College of Rheumatology (ACR), without the need of tender points palpation, allows that larger and nationwide surveys may be done, worldwide. This article reviews the prevalence and incidence studies done in the general population, in several countries/continents, the prevalence of FM in special groups/settings, the association of FM with some sociodemographic characteristics of the population, and the comorbidity of FM with others disorders, especially with headaches.

Medication-overuse headache

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is a well described clinical entity. There is a growing body of knowledge on the epidemiology of MOH, risk factors, and treatment strategies.

RECENT FINDINGS

The International Headache Society updated the classification criteria for MOH. Population-based studies provided an insight into the prevalence and peculiarities of MOH patients in eastern Europe and Asia. Large-scaled population-based longitudinal studies made it possible to analyze risk factors leading to the development of MOH. Imaging studies helped to better understand the pathophysiology of headache chronicity. New treatment strategies have been suggested.

SUMMARY

MOH is a common headache disorder and a serious public health problem all over the world. Although the treatment regimen for MOH patients is straightforward and the outcomes are favorable, it is time now to move forward and establish a predictive model for early recognition of patients at high risk, to intervene early and avoid development of chronic headache.

Evaluating the prophylaxis and long-term effectiveness of acupuncture for migraine without aura: study protocol for a randomized controlled trial

BACKGROUND

The instant-treatment effect of acupuncture for patients with migraines has been corroborated in numerous studies. However, most diseases are chronic and tend to recur, so the long-term effect of acupuncture can verify the existence of sustained efficacy or the placebo effect. Evaluating the efficacy of acupuncture in the prophylaxis of migraine without aura (MWoA) in China is also important because such studies are lacking.

METHODS

This trial is a multicenter, prospective, pragmatic randomized controlled clinical trial. We will randomly allocate 249 participants to three groups of 83. Patients in the individualized acupoint group will be treated with individualized acupuncture point prescriptions. The non-acupoint control group will undergo insertion of acupuncture needles at four bilateral non-points in locations not corresponding to acupuncture points. The waiting-list control group will not undergo treatment but instead will receive 20 acupuncture treatments for free after a waiting period of 24 weeks. Participants in the individualized acupoint group and non-acupoint control group will receive 20 sessions over four weeks and then all participants will receive 20 weeks of follow-up.

DISCUSSION

The results of our trial will help to supply evidence for the long-term acupuncture effect for MWoA in a long follow-up period, and special attention will be paid to comparison with the placebo effect.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov (NCT01687660) on 18 September 2012.

Sex-related differences in epidemiological and clinic-based headache studies

This manuscript discusses sex-related differences in headache prevalence, the symptoms and natural history of migraine, associated disability, and co-morbid disorders. The role of sex hormones is discussed with reference to the effects of hormonal events across the reproductive years and the specific effects of the menstrual cycle on migraine. Differences between the sexes were identified across all parameters reviewed. Future research should ensure that data are analyzed separately for men and women to ensure that differences between the sexes are identified.

Latin American consensus on guidelines for chronic migraine treatment

Chronic migraine is a condition with significant prevalence all around the world and high socioeconomic impact, and its handling has been challenging neurologists. Developments for understanding its mechanisms and associated conditions, as well as that of new therapies, have been quick and important, a fact which has motivated the Latin American and Brazilian Headache Societies to prepare the present consensus. The treatment of chronic migraine should always be preceded by a careful diagnosis review; the detection of possible worsening factors and associated conditions; the stratification of seriousness/impossibility to treat; and monitoring establishment, with a pain diary. The present consensus deals with pharmacological and nonpharmacological forms of treatment to be used in chronic migraine.

A case of postural orthostatic tachycardia syndrome associated with migraine and fibromyalgia

Postural orthostatic tachycardia syndrome (POTS) refers to the presence of orthostatic intolerance with a heart rate (HR) increment of 30 beats per minute (bpm) or an absolute HR of 120 bpm or more. There are sporadic reports of the autonomic nervous system dysfunction in migraine and fibromyalgia. We report a case of POTS associated with migraine and fibromyalgia. The patient was managed with multidisciplinary therapies involving medication, education, and exercise which resulted in symptomatic improvement. We also review the literature on the association between POTS, migraine, and fibromyalgia.

Direct medical costs and medication compliance among fibromyalgia patients: duloxetine initiators vs. pregabalin initiators

OBJECTIVES

To assess and compare direct medical costs and medication compliance between patients with fibromyalgia who initiated duloxetine and patients with fibromyalgia who initiated pregabalin in 2008.

METHODS

A retrospective cohort study design was used based on a large US national commercial claims database (2006 to 2009). Patients with fibromyalgia aged 18 to 64 who initiated duloxetine or pregabalin in 2008 and who had continuous health insurance 1 year preceding and 1 year following the initiation were selected into duloxetine cohort or pregabalin cohort based on their initiated agent. Medication compliance was measured by total supply days, medication possession ratio (MPR), and proportion of patients with MPR ≥ 0.8. Direct medical costs were measured by annual costs per patient and compared between the cohorts in the year following the initiation. Propensity score stratification and bootstrapping methods were used to adjust for distribution bias, as well as cross-cohort differences in demographic, clinical and economic characteristics, and medication history prior to the initiation.

RESULTS

Both the duloxetine (n = 3,033) and pregabalin (n = 4,838) cohorts had a mean initiation age around 49 years, 89% were women. During the postindex year, compared to the pregabalin cohort, the duloxetine cohort had higher totally annual supply days (273.5 vs. 176.6, P < 0.05), higher MPR (0.7 vs. 0.5, P < 0.05), and more patients with MPR ≥ 0.8 (45.1% vs. 29.4%, P < 0.05). Further, relative to pregabalin cohort, duloxetine cohort had lower inpatient costs ($2,994.9 vs. $4,949.6, P < 0.05), lower outpatient costs ($8,259.6 vs. $10,312.2, P < 0.05), similar medication costs ($5,214.6 vs. $5,290.8, P > 0.05), and lower total medical costs ($16,469.1 vs. $20,552.6, P < 0.05) in the postinitiation year.

CONCLUSIONS

In a real-world setting, patients with fibromyalgia who initiated duloxetine in 2008 had better medication compliance and consumed less inpatient, outpatient, and total medical costs than those who initiated pregabalin.

The prevalence of fibromyalgia and its relation with headache characteristics in episodic migraine

The objective of this study was to assess the prevalence of fibromyalgia (FM) in patients with episodic migraine and to evaluate the relationship between migraine characteristics and FM. One hundred and eighteen consecutive patients (mean age = 38 years, 75% women) fulfilling the International Classification of Headache Disorders-II criteria for migraine with (n = 22) and without (n = 96) aura from an outpatient headache clinic of a university hospital were evaluated. The diagnosis of FM was made based on the 1990 American College of Rheumatology classification criteria. Participants completed some self-administered questionnaires ascertaining sociodemographics, headache severity, frequency and duration, headache-related disability (Headache Impact Test [HIT-6]) and Migraine Disability Assessment Scale, widespread musculoskeletal pain (visual analog scale), depression (Beck depression inventory), anxiety (Beck anxiety inventory), sleep quality (Pittsburgh Sleep Quality Index), fatigue (Multidimensional Assessment of Fatigue), and quality of life (Short Form-36 Health Survey [SF-36]). In patients with FM, the tender point count and the Fibromyalgia Impact Questionnaire were employed. FM was diagnosed in 37 (31.4%) of the patients. FM comorbidity was equally distributed across patients with and without aura. Severity of migraine headache, HIT-6, and anxiety were especially associated with FM comorbidity. Patients suffering from migraine plus FM reported lower scores on all items of the SF-36. This study indicates that the assessment and management of coexisting FM should be taken into account in the assessment and management of migraine, particularly when headache is severe or patients suffer from widespread musculoskeletal pain.

Characteristics of referred muscle pain to the head from active trigger points in women with myofascial temporomandibular pain and fibromyalgia syndrome

Our aim was to compare the differences in the prevalence and the anatomical localization of referred pain areas of active trigger points (TrPs) between women with myofascial temporomandibular disorder (TMD) or fibromyalgia (FMS). Twenty women (age 46 ± 8 years) with TMD and 20 (age 48 ± 6 years) with FMS were recruited from specialized clinic. Bilateral temporalis, masseter, sternocleidomastoid, upper trapezius, and suboccipital muscles were examined for TrPs. TrPs were identified by palpation and considered active when the pain reproduced familiar pain symptom experienced by the patient. The referred pain areas were drawn on anatomical maps, digitalized and also measured. A new analysis technique based on a center of gravity (COG) method was used to quantitative estimate of the localization of the TrP referred pain areas. Women with FMS exhibited larger areas of usual pain symptoms than women with myofascial TMD (P < 0.001). The COG coordinates of the usual pain on the frontal and posterior pain maps were located more superior in TMD than in FMS. The number of active TrPs was significantly higher in TMD (mean ± SD 6 ± 1) than in FMS (4 ± 1) (P = 0.002). Women with TMD exhibited more active TrPs in the temporalis and masseter muscles than FMS (P < 0.01). Women with FMS had larger referred pain areas than those with TMD for sternocleidomastoid and suboccipital muscles (P < 0.001). Significant differences within COG coordinates of TrP referred pain areas were found in TMD, the referred pain was more pronounced in the orofacial region, whereas the referred pain in FMS was more pronounced in the cervical spine. This study showed that the referred pain elicited from active TrPs shared similar patterns as usual pain symptoms in women with TMD or FMS, but that distinct differences in TrP prevalence and location of the referred pain areas could be observed. Differences in location of referred pain areas may help clinicians to determine the most relevant TrPs for each pain syndrome in spite of overlaps in pain areas.